The impact of dehydration on short-term postoperative complications in total knee arthroplasty.

BACKGROUND: As healthcare economics shifts towards outcomes-based bundled payment models, providers must understand the evolving dynamics of medical optimization and fluid resuscitation prior to elective surgery. Dehydration is an overlooked modifiable risk factor that should be optimized prior to elective total knee arthroplasty (TKA) to reduce postoperative complications and inpatient costs. METHODS: All primary TKA from 2005 to 2019 were queried from the National Surgical Quality Improvement Program (NSQIP) database, and patients were compared based on dehydration status: Blood Urea Nitrogen Creatinine ratio (BUN/Cr) < 20 (non-dehydrated), 20 ≤ BUN/Cr ≤ 25 (moderately-dehydrated), 25 < BUN/Cr (severely-dehydrated). A sub-group analysis involving only elderly patients > 65 years and normalized gender-adjusted Cr values was also performed. RESULTS: The analysis included 344,744 patients who underwent TKA. Adjusted multivariate logistic regression analysis showed that the severely dehydrated cohort had a greater risk of non-home discharge, postoperative transfusion, postoperative deep vein thrombosis (DVT), and increased length of stay (LOS) (all p < 0.01). Among the elderly, dehydrated patients had a greater risk of non-home discharge, progressive renal insufficiency, urinary tract infection (UTI), postoperative transfusion, and extended LOS (all p < 0.01). CONCLUSION: BUN/Cr > 20 is an important preoperative diagnostic tool to identify at-risk dehydrated patients. Providers should optimize dehydration to prevent complications, decrease costs, and improve discharge planning. LEVEL OF EVIDENCE: Level III; Retrospective Case-Control Design; Prognosis Study.

A 15-year retrospective analysis of prognostic factors in childhood bacterial meningitis.

AIM: This retrospective chart review aimed to identify factors in childhood bacterial meningitis that predicted disease severity and long-term outcome. METHODS: The study included 112 episodes of microbiologically confirmed bacterial meningitis in children aged three days to 15 years who were admitted to a Singapore hospital from 1998 to 2013. RESULTS: The mortality rate was 6%, and 44% required intensive care unit (ICU) admission. Predictive factors associated with ICU admission included pneumococcal meningitis, with an odds ratio (OR) of 5.2 and 95% confidence interval (CI) of 1.5-18.2, leukopenia (OR 5.6, 95% CI 1.7-17.9) and a cerebrospinal fluid (CSF):serum glucose ratio <0.25 (OR 4.5, 95% CI 1.4-14.4). An initial CSF white blood cell count >1000/mm(3) (OR 0.26, 95% CI 0.086-0.76) was negatively associated with ICU admission. Five years after meningitis, 32% had residual sequelae, and the associated prognostic factors were Haemophilus influenzae type b (Hib) meningitis (OR 29.5, 95% CI 2-429), seizures during their inpatient stay (OR 10.6, 95% CI 1.9-60.2) and septic shock (OR 8.4, 95% CI 1.1-62.1). CONCLUSION: As mortality was low in this bacterial meningitis study, ICU admission was used as a marker of disease severity. These findings underscore the importance of the pneumococcal and Hib meningitis vaccines.

Approach to difficult-to-treat asthma in childhood: a narrative review.

ABSTRACT: Asthma is a major chronic disease affecting children, and children with difficult-to-treat asthma account for a disproportionate share of resource utilisation and healthcare costs. This review presents a comprehensive and up-to-date overview of the treatment strategies in difficult-to-treat paediatric asthma. Mimickers of asthma must first be ruled out, and the diagnosis confirmed with objective tests whenever possible. The effect of comorbid conditions such as obesity, smoking, other atopic conditions and psychosocial factors on asthma control and severity should be considered. Treatment can then be optimised by implementing personalised strategies, including the use of appropriate drug delivery devices and adherence monitoring. Biologics can be an alternative treatment option for selected patients but should not be a substitute for addressing poor adherence. Many patients with difficult-to-treat asthma may not have severe asthma, and the physician should work with patients and families to achieve good asthma control via an individualised approach.

Repeat High-Dose Dexamethasone May Improve Recovery 48 Hours after Total Hip Arthroplasty.

Objectives: Perioperative dexamethasone is an effective anti-emetic and systemic analgesic in total hip arthroplasty (THA) that may reduce opioid consumption and enhance rapid recovery. However, there is no consensus on the optimal perioperative dosing that is safe and effective for faster rehabilitation and improved pain control while maintaining safe blood glucose levels. Methods: A retrospective review of 101 primary THA patients at a single institution who received perioperative dexamethasone was conducted. Patients were stratified by dexamethasone induction dosage (10 mg as high, <6mg as low) and whether a repeat dose was given 16-24 hours postoperatively. Age, gender, BMI, diabetes status, and ASA were controlled between groups. The pain was evaluated with inpatient morphine milligram equivalents (MME) requirements and visual analog scale (VAS) at 8, 16, and 24 hours postoperatively. Mobility was assessed by inpatient ambulation distance, Boston AM-PAC mobility score, and percentage of gait assistance as determined by a physical therapist. Secondary outcomes included postoperative nausea and vomiting (PONV) limiting therapy sessions, PONV requiring breakthrough anti-emetics, glucose levels, surgical site infection, wound healing complications, and discharge destination. Results: Compared to patients receiving one dose of high or low dexamethasone, patients receiving two dosages of high-dose dexamethasone had significantly further ambulation distance and lower percentage of gait assistance on postoperative day 2. A generalized linear model also predicted that any repeat dexamethasone, regardless of dosage, significantly improved ambulation distance and gait assistance compared to the one-dose cohort. There was no statistically significant difference between VAS scores, MME requirements, PONV, postoperative glucose levels >200, discharge destination, or risk of infection between groups. Conclusion: A repeat high-dose dexamethasone, the morning after surgery, may improve percentage of gait assistance and ambulation endurance on postoperative day two. There was no risk of uncontrolled glucose levels or infections compared to receiving one dose of dexamethasone at induction.

Chlorhexidine gluconate lavage during total joint arthroplasty may improve wound healing compared to dilute betadine.

PURPOSE: Intraoperative wound irrigation prior to closure during total joint arthroplasty (TJA) is an essential component of preventing infections and limiting health care system costs. While studies have shown the efficacy of dilute betadine in reducing infection risk, there remains concerns over its safety profile and theoretical inactivation by blood and serum. This study aims to compare infection and wound complications between chlorhexidine gluconate (CHG) and betadine lavage during TJA. METHODS: All primary TJA between 2019-2021 were analyzed at a single institution, and periprosthetic joint infection (PJI), wound drainage, 30 and 90-day emergency room (ER) readmission due to wound complications, aseptic loosening, and revision surgery rate were compared between patients undergoing intraoperative CHG versus betadine lavage prior to closure. Baseline demographics were controlled, and multivariate logistic regression was performed to compare complication rates. RESULTS: A total of 410 TJA, including 160 hip and 250 knee arthroplasties were included. Compared to the dilute betadine cohort, all TJA patients undergoing CHG lavage had a statistically significant lower 30 and 90-day emergency room readmission rate due to wound complications. Both hip and knee arthroplasty patients with CHG had a statistically significant lower rate of postoperative superficial drainage and dressing saturation at clinic follow-up, but only knee arthroplasty patients had significant decreased readmission rate for incisional wound vacuum placement and close inpatient monitoring of wound healing. Among all TJA, there was no significant association in the rate of PJI requiring return to the OR between groups. CONCLUSIONS: Although betadine is cost-effective and has been shown to reduce PJI rates, there remains concerns in the literature over soft tissue toxicity and wound healing. This study suggests CHG may be as efficacious as dilute betadine in preventing PJI while also decreasing the risk of superficial drainage and wound complications needing unplanned ER visits during the acute postoperative period.

Langerhans cell histiocytosis: an unusual cause of vesicular rashes in a neonate.

The skin manifestations of Langerhans cell histiocytosis (LCH) in the neonate have a heterogenous presentation and can mimic other causes of neonatal rashes. We report an uncommon case of LCH in a term female neonate presenting with non-specific papules and vesicles from the first day of life. There was a maternal history of genital herpes simplex virus (HSV) infection in the third trimester. Blood, cerebrospinal fluid, surface swabs and vesicular fluid were negative for HSV by PCR, and a skin biopsy confirmed the diagnosis of LCH. Further investigations for systemic involvement returned negative. Our case emphasises the variable and non-specific presentation of neonatal cutaneous LCH, which can progress to or be part of multisystem disease.